SPECIAL ARTICLE
based on the Presidential Address given at the
30th Annual Meeting of the American Academy of Psychiatry and the Law,
Baltimore, MD, October 14, 1999

Ensuring That Forensic Psychiatry Thrives as a Medical Specialty
in the 21st Century

Larry R. Faulkner, MD

The author contends that forensic psychiatry will thrive as a
legitimate medical specialty in the 21st century only if it helps to
fulfill the crucial requirement of medical systems in the new health
care era. The article presents six basic requirements of future medical
systems: effective, efficient, and responsible organizations; quality
educational programs of the appropriate type and size; linkage to
health care networks; primary care capacity and services; restructured
systems for research; and effective leadership. Specific opportunities
for forensic psychiatry to help meet these requirements are outlined.
The author presents major implications of these opportunities for
forensic academicians and practitioners as well as for the American
Academy of Psychiatry and the Law.

J Am Acad Psychiatry Law 28(1): 14-20, 2000

If we could first know where we are, and
whither we are tending, we could then better judge what to do, and how
to do it.-Abraham Lincoln1

As the 21st century dawns, dramatic
changes are taking place in medicine, and predictions of gloom and doom
are commonplace.2, 3 The uncertainties of the
time have underscored the need for careful strategic planning and a
critical reassessment of educational, research, and service
programs.4, 5 There is a growing awareness that
we are indeed in an era of fiscal restraint that calls for an increased
emphasis on the effectiveness, efficiency, and relevance of all
programs.6-9

If forensic psychiatry is to thrive as a legitimate specialty of
medicine in the new health care era, I believe it must step boldly into
the 21st century with clear strategic processes that demonstrate its
value and relevance. My basic premise is that forensic psychiatry will
be regarded as a valuable medical specialty to the extent that it helps
to fulfill the crucial requirements of all of medicine. If forensic
psychiatry is perceived by medical systems as helpful, its stature will
grow, and it may even prosper in the new era. However, if forensic
psychiatry is perceived as not helpful, it will either be eliminated as
an unnecessary expense or ignored as an unimportant "hobby" at the
fringe of legitimate medicine. If my premise is true, then it also
follows that for forensic psychiatry to be most helpful to the rest of
medicine it must move aggressively to meet basic requirements of future
medical systems.

The major goals of this article, therefore, are to identify what I
believe will be the specific requirements of medical systems in the new
health care era, to suggest opportunities for forensic psychiatry to
fulfill those requirements, and to outline selected implications of
these opportunities for forensic academicians and practitioners as well
as for the American Academy of Psychiatry and the Law.

It is important for me to state several personal assumptions and
underlying perspectives that will surely influence this discussion.
First, I believe strongly that forensic psychiatry should remain a
specialty of psychiatry and of medicine. Forensic psychiatrists are
physicians first, psychiatrists second, and only then forensic
psychiatrists. Second, my opinions about the issues in this article are
drawn from the admittedly biased perspective of academic
administration. Individuals in other positions might well have
different opinions about the issues I discuss. Third, certain aspects
of forensic psychiatry, such as private forensic practice, will surely
not be emphasized adequately. I must leave those issues to others with
greater expertise. Finally, this discussion will focus mainly on the
activities of forensic psychiatry within the medical system and not the
legal system. Again, I must let others with more expertise consider
what the future activities of forensic psychiatrists in the legal arena
should be.

Six Requirements of Medical Systems: Opportunities for Forensic
Psychiatry

As first outlined by Bloom and me10
elsewhere, I believe that future medical systems will need to fulfill
the following six basic requirements to respond adequately to the
forces at work in the new health care era. I do not mean to imply that
these requirements are all that will be necessary. There are most
certainly other crucial elements that are either not apparent to me at
this time or that will arise in the future. The six requirements I
describe below are merely those that currently seem most pertinent to
me. There is some overlap among several of these requirements, and I
have divided them to facilitate discussion. They are not presented in
any particular order of priority.

Requirement 1: Organizations That Are Effective, Efficient, and
Responsible

All of society is under increasing scrutiny by a public that is
demanding more accountability and better management of scarce
resources.11 For example, although the nation's
125 medical schools have experienced significant public support and
tremendous growth in revenues over the last several decades, they too
are facing tough questions about the effectiveness and efficiency of
their educational, research, and clinical service
programs.12-14 To maintain credibility, future
medical systems will need to demonstrate that their programs are not
only effective, but also efficient, consistent with existing laws and
regulations, and relevant to the needs of the citizens who support
them. This has obvious implications for administrative, strategic
planning, and financial management systems employed by medical
institutions, as well as for the expertise required by deans,
department chairs, and other medical
administrators.2, 9

To meet this requirement, forensic psychiatry should:

1. Initiate strategic planning processes to delineate how forensic
psychiatry can contribute to the overall goals of medicine and specific
medical systems.

2. Document the effectiveness of forensic educational, research, and
service programs in fulfilling specific community needs.

3. Maintain the fiscal integrity of all forensic programs.

4. Respond to regulatory and legal requirements in a manner that sets
an example for other medical programs in the system.

5. Adopt a spirit of flexibility and cooperation as well as a
willingness to modify existing programs to respond to new medical
system requirements and opportunities.

In recent years, discussions of medical workforce size and
characteristics have assumed center stage in a debate that has been at
times strident and acrimonious.15, 16 In
general, there seems to be a consensus that the United States has too
many physicians, too many specialists, too few generalists, a
geographic and sociocultural maldistribution of the physician
workforce, and significant deficiencies in the training of physicians
to practice in modern service-delivery
systems.17, 18 Academic medicine is under
pressure to demonstrate that its trainees are being prepared in
appropriate numbers and types and with the knowledge, skills, and
attitudes required to serve adequately the public in the new health
care era.7, 19 This requirement mandates
that academic medicine design its educational programs in a manner that
is consistent not only with its own needs but also with local, state,
and national workforce requirements. It also dictates that emphasis be
placed on the quality rather than on the number of graduates, that
careful consideration be given to the educational needs of primary care
trainees, that multidisciplinary training experiences be developed, and
that training be expanded into alternative sites available in new
service-delivery systems.

To meet this requirement, forensic psychiatry should:

1. Demonstrate the need for forensic psychiatrists at the local, state,
and national levels.

2. Emphasize the quality rather than the number of programs and
trainees.

3. Focus attention on the forensic educational needs of medical
students and non-psychiatry residents.

Requirement 3: Participation in Health Care Networks

In the last several years, medical administrators as well as
individual practitioners of all types have been seeking strategies that
might help them receive a steady flow of
patients.2 One of the most common approaches has
been the participation in health care networks that develop integrated
systems capable of providing a full range of specific services and
levels of care.20 Through innovative marketing,
aggressive contracting, decentralization of services, referral of
patients within the network, increased efficiency, and economies of
scale, these networks hope to be able to compete for patients with
other integrated systems in the medical
marketplace.21 In the modern health care era, it
is clear that a high premium will be placed on those strategies that
are able to expand network services into new areas and to bring
additional, funded patients into the system.

To meet this requirement, forensic psychiatry should:

1. Develop special forensic services that increase the value and
competitiveness of the overall medical system to potential customers
(e.g., legal medicine consultations; ethics programs and
consultations).

Requirement 4: Primary Care Capacity and Services

In the managed care era, primary care has become a key element of
the foundation upon which most modern health care networks are built,
because control over primary care also exerts significant influence
over subspecialty and hospital referrals.5 These
facts have led medical administrators to adopt aggressive strategies to
expand their own primary care capacity and services, form linkages with
primary care groups in the community, or
both.20, 21 A common theme throughout all of
these strategies is their significant cost to the system, not just in
revenue but also in the time and energy commitment required of
administrators to implement them.2 Because of the
financial risks involved, a health care network must take steps to
ensure that its primary care services are efficient and that it obtains
the maximum primary care capacity possible for its
investment.9, 20 Any reasonable strategies for
increasing primary care services or capacity within existing resources
are likely to be warmly received by network administrators.

Requirement 5: Restructured Systems for Research

Perhaps academic medicine's most striking success over the past
half century has been its contribution to our nation's preeminent
position in medical research.22 These efforts
have been funded through a combination of federal, state, and private
resources as well as from revenues generated by clinical services.
Threats exist to the integrity of each of these traditional sources of
funding in the new era,2 and it appears unlikely
that academic medicine will be able to maintain current levels of
research effort without a serious reconsideration of the structure and
function of existing programs.8, 20 This
requirement might very well lead to a reorganization of medical
systems to promote efficiency and to be more consistent with
multidisciplinary research requirements.2, 3 It
almost certainly will entail a much closer collaboration between
academic medicine and private industry as well as a willingness to
focus on issues pertaining to health service delivery in more
nontraditional systems of care.5, 20

To meet this requirement, forensic psychiatry should:

1. Develop multidisciplinary forensic research collaborations.

2. Focus on forensic aspects of health services research relevant to
the medical and forensic systems.

5. Expand research linkages with state and federal institutions (e.g.,
departments of mental health, juvenile justice, and corrections; the
Veterans Administration).

Requirement 6: Effective Leadership

The diverse and complex challenges in the new health care era will
require talented and courageous leaders. Medical systems must be
organized more like businesses, with streamlined operations and
effective methods for financial analysis, cost allocation, and the
careful assessment of potential markets for educational, research, and
service products.12, 13 New models of
organizations may be required, as well as modification in the roles and
responsibilities of administrators and
practitioners.9 These changes may well mandate an
evolution in the basic culture of medicine, as emphasis is placed on
the documentation of performance in market terms rather than more
traditional medical measures.2 To manage these
difficult transitions, medical leaders must be able to develop and
implement effective strategic planning processes that identify the
major elements of a program's mission. The leaders must also set a
realistic yet challenging vision for the future, clarify basic
operating principles that will govern the enterprise, and outline
specific objectives that capitalize on the unique capabilities of
system participants as well as local market
conditions.23 These complex tasks will require
that medical leaders possess not only stellar academic credentials, but
also the special administrative knowledge and skills required to
analyze and manage increasingly complicated health care systems.

Implications for Forensic Academicians, Practitioners, and the
American Academy of Psychiatry and the Law

I believe the opportunities I have outlined for forensic
psychiatry to respond to the basic requirements of medical systems in
the 21st century have important implications for forensic academicians
and practitioners, as well as for the American Academy of Psychiatry
and the Law. Space and knowledge limitations prevent me from listing
all of the conceivable implications of the opportunities I have
suggested. Instead, I will again outline those that seem most pertinent
to me at this time. For ease of presentation, I will organize my
recommendations into sections titled Assess,
Participate, Provide, Lead, and
Educate. As can be seen, the first letters of each section
quite appropriately spell "APPLE," the name commonly associated
with the American Academy of Psychiatry and the Law (the AAPL).

Implications for Forensic Academicians

Forensic academicians who wish to be productive and valuable
members of their academic medical systems in the new health care era
must do the following.

Assess

Evaluate the administrative needs of modern medical systems, and
of effective and efficient educational, research, and service programs,
and obtain the knowledge and skills necessary to fulfill medical system
requirements.

Participate

Collaborate with other medical and mental health professionals in
developing multidisciplinary educational, research, and service
programs, and establish relationships with other institutions and
potential customers that might be of value to the entire academic
medical system.

Provide

Establish forensic educational, research, and service programs
that emphasize quality rather than quantity, and ensure the
administrative, fiscal, and legal integrity of all forensic programs.

Lead

Pursue administrative and leadership roles in academic medical
systems, and maintain a spirit of flexibility and cooperation with the
efforts of academic medical system leaders.

Educate

Participate in educational programs for medical students and
non-psychiatry residents, and establish educational programs in
non-academic settings.

Implications for Forensic Practitioners

Forensic practitioners who wish to be productive and valuable
members of their medical systems in the new health care era must do the
following.

Assess

Evaluate personal readiness to meet the forensic needs of modern
medical systems, and correct specific knowledge and skill deficiencies.

Participate

Become involved in the forensic services in medical systems, and
embrace new multidisciplinary interactions with other medical and
mental health professionals.

Provide

Emphasize quality consultation and service that fulfills the
requirements of the medical system, and maintain strict adherence to
legal and ethical requirements in all professional activities.

Lead

Become involved and assume leadership roles in medical systems and
medical organizations, and support efforts to advocate for an expanded
role for forensic psychiatry in medical systems.

Educate

Participate in the educational programs in medical systems, and
ensure that personal knowledge and skills are adequate to fulfill
current requirements of educational programs.

Implications for the American Academy of Psychiatry and the Law

The American Academy of Psychiatry and the Law must be willing to
assist forensic psychiatrists in their efforts to thrive as a medical
specialty in the new health care era. The Academy should do the
following.

Assess

Evaluate the forensic educational, research, and service needs of
modern medical systems, and encourage the increased participation of
forensic psychiatrists in fulfilling medical system requirements.

Participate

Increase active liaison with other national medical organizations,
and promote forensic psychiatrists as leaders within medical systems
and organizations.

Provide

Develop practice guidelines for common forensic psychiatry
activities, and establish a Forensic Psychiatry Education and Research
Institute to support focused educational and research projects
demonstrating the value of forensic psychiatry to medical systems.

Lead

Advocate for a broadening of the scope of practice of forensic
psychiatry to include expertise in the administration of medical
systems, and promote educational, research, and service collaborations
that demonstrate the value of forensic psychiatry to medical systems
and their potential customers.

Educate

Develop educational programs that are specifically designed to
teach forensic academicians and practitioners the pertinent leadership,
administrative, educational, research, and clinical knowledge and
skills required in modern medical systems, and encourage the increased
participation of forensic psychiatrists in the education of medical
students and non-psychiatry residents.

Conclusions

This is an historic time for all of medicine. The basic
requirements of medical systems in the 21st century will determine the
structure and function of future medical programs and specialties.
Although much has been accomplished by physicians over the past several
decades, new knowledge, skills, and attitudes will be required to
participate effectively in and lead modern medical systems. All of the
changes and uncertainties of the new health care era will certainly
present many challenges to be overcome, but new opportunities will also
surely exist for those physicians and medical organizations ready to
confront them in a positive and constructive manner. It is my firm
belief that forensic psychiatry can solidify an important role for
itself within the mainstream of medicine in the 21st century. This will
only be possible, however, if forensic academicians, practitioners, and
the American Academy of Psychiatry and the Law prepare themselves now
to take advantage of the opportunities that will arise. They must set
aside whatever past success they have had and meet future challenges
with a spirit akin to that so well articulated by Abraham Lincoln many
years ago:

Still the question recurs "can we do better?" The dogmas of
the quiet past are inadequate to the stormy present. The occasion is
piled high with difficulty, and we must rise with the occasion. As our
case is new, so we must think anew, and we must act anew . We
must disenthrall ourselves.24

Dr. Faulkner is Vice President for Medical Affairs and Dean,
School of Medicine, University of South Carolina; he is also the
immediate Past President, American Academy of Psychiatry and the Law.
This paper is based in part on the Presidential Address given at the
30th Annual Meeting of the American Academy of Psychiatry and the Law,
Baltimore, MD, October 14, 1999. Address correspondence to: Larry R.
Faulkner, MD, Vice President for Medical Affairs and Dean, School of
Medicine, University of South Carolina, Columbia, SC 29208.